MEDICARE: DR. DENNIS LONG DHSC, CCP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	242T00000X	Perfusionist	214000255	IL

General Provider Information

NPI Number	:	1952924961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DENNIS LONG DHSC, CCP

Provider Business Mailing Address
First Line	:	1440 CIRCLE DR
Second Line	:
City	:	GLENDALE HEIGHTS
State	:	IL
Zip	:	60139-3310
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1440 CIRCLE DR
Second Line	:
City	:	GLENDALE HEIGHTS
State	:	IL
Zip	:	60139-3310
Country	:	US
Telephone Number	:	847-722-3830
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2020
Last Update Date	:	05/26/2020

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